Curr Geri Rep (2017) 6:15–19
DOI 10.1007/s13670-017-0197-x
GERIATRIC ORTHOPEDICS (E MEINBERG, SECTION EDITOR)
Geriatric Orthopaedics: a New Paradigm for Management
of Older Patients
Carmen E. Quatman 1,2 & Julie A. Switzer 1,2
Published online: 13 February 2017
# Springer Science+Business Media New York 2017
Abstract
Purpose of Review Fragility fractures have become a world-
wide epidemic that has necessitated a paradigm shift in how
we approach the care for elderly orthopaedic patients. There is
a great need for subspecialty trained orthopaedic surgeons to
help bridge the gap and help with transition of care in geriatric
orthopaedic patients.
Recent Findings Not only are the surgical needs of elderly
patients different than younger patients but often the complex-
ity of co-morbidities and bio-psychosocial needs are impor-
tant considerations for patient care and outcomes.
Summary Geriatric orthopaedic fellowship training is a cru-
cial paradigm shift to provide the most efficient, safe, support-
ive, and cost-effective musculoskeletal healthcare for elderly
patients.
Keywords Geriatric orthopaedics . Fragility fracture .
Orthopaedic fellowship training . Bone health . Osteoporosis
Background on Need of Subspecialty Training
of Orthopaedic Surgeons
Fractures in the elderly population can lead to profound mor-
bidity, mortality, and social and financial consequences for
This article is part of the Topical Collection on Geriatric Orthopedics
* Julie A. Switzer
Julie.a.switzer@healthpartners.com
1
Department of Orthopaedic Surgery, Regions Hospital, 640 Jackson
St., St. Paul, MN 55101, USA
2
Department of Orthopaedic Surgery, University of Minnesota,
Minneapolis, MN, USA
patients. While orthopaedics has a large subspecialty base
including hand, spine, sports medicine, trauma, musculoskel-
etal oncology, foot and ankle, pediatrics, and shoulder and
elbow, the current approach to geriatric orthopaedics is rela-
tively generalized. In 2003, over 51% of orthopaedic surgery
work was in people 65 years of age or older [1]. Population
demographics are shifting in the USA, with 43 million people
age 65 or older in the USA projected to nearly double to 84
million by 2050 [2, 3]. The total number of orthopaedic cases
in the elderly has increased dramatically over the past decade,
which dictates the need for a paradigm shift in our approach to
orthopaedic care for elderly patients.
In response to the growing elderly population and concom-
itant increase in fragility fractures, the American Orthopaedic
Association created the “Own the Bone” program to encour-
age hospitals and medical centers to identify, evaluate, and
treat fragility fracture patients over the age of 50 years for
osteoporosis. The “Own the Bone” program’s goal to change
physician and patient behavior to reduce incidence of future
fractures and the impact of osteoporosis is one important step
in addressing the unique musculoskeletal needs in older pa-
tients [4]. However, the time sequential deterioration in
strength, mobility, and agility with increased susceptibility to
disease and injury associated with aging is an important con-
cept to acknowledge in the medical treatment of patients. In
particular, older individuals have a decreased ability to re-
spond to physiologic stress and often multiple morbidities that
make treatment and recovery from illness or injury more chal-
lenging than in the younger patient. Coincident with the bio-
logical aging process, the bio-psychosocial needs of the older
patients are often different than younger patients and the out-
come expectations following injury and disease may often
have to be tempered from thoughts of “cure” to thoughts of
disease management, maintaining quality of life, and meeting
goals of care [5].
16
Despite improvements in surgical techniques and medical
management of co-morbidities such as osteoporosis through
concepts like “Own the Bone,” up to 50% of fragility fracture
patients show substantial decline in activities of daily living
compared to pre-injury status, and have a 15–30% risk of
mortality within 1 year after fracture. It is paramount that
our orthopaedic specialty leads the way in determining how
to provide the most efficient, effective, safe, and supportive
musculoskeletal healthcare possible for older patients, while
continuing to focus on minimizing healthcare system costs.
This calls for a paradigm shift in the current practice of ortho-
paedic medicine in older patients [6•]. As awareness of the
complex musculoskeletal needs of the aging patient continues
to grow, it is time that the field of orthopaedics follows in the
footsteps of other specialties such as internal medicine, neu-
rology, psychiatry, nephrology, oncology, dermatology, and
emergency medicine, to create a subspecialty of geriatric or-
thopaedics designed to address the unique needs of the aging
population. This report will outline the motivation and an
innovative approach to creating fellowship training for ortho-
paedic surgeons in order to create, promote, and evolve the
field of Geriatric Orthopaedics.
Geriatric Orthopaedics
The field of orthopaedics aims to promote health by
preventing and treating diseases and disabilities associated
with the musculoskeletal system. Within this framework, the
impairments that orthopaedic surgeons often address are relat-
ed to mobility and function. Musculoskeletal changes associ-
ated with aging include decreased muscle mass and strength,
decreased bone density, loss of skeletal height, joint pain and
stiffness, increased fracture risk, and alterations in gait, bal-
ance, and posture [5]. Combined with sensory losses in visual
acuity, depth perception, hearing acuity, and proprioception,
the aging population is at high risk for falls and subsequent
injury with high morbidity and mortality [7•]. Approach to an
elderly patient often necessitates special attention to these im-
pairments and it is imperative that we develop a more elder-
oriented orthopaedic approach for best practices in the geriat-
ric population.
Geriatric Fellowship Goals
Orthopaedic specialty training that enriches and promotes the
understanding of palliative care, multi-morbidity, frailty, and
general geriatric competencies helps to ensure optimized care
for older patients. Orthopaedic residencies prepare surgeons to
perform fracture care in a variety of settings. However, it is
challenging to incorporate extensive training in bone health
and wellness into the current model of training. Instead,
Curr Geri Rep (2017) 6:15–19
focused apprenticeship that allows for a deep dive into the
health, wellness, and medical competencies necessary to pro-
vide optimal care of older patients could potentially positively
impact the morbidity and mortality of geriatric orthopaedic
patients.
Goals of specialty training in geriatric orthopaedics include
exposure to and participation in the evidence-based clinical
care of elder fracture and trauma patients. It emphasizes com-
prehensive care of elderly orthopaedic patients in the hospital,
clinic, and nursing facilities. In particular, fellows should de-
velop an understanding of the entire course of care for the
elderly patient from pre-hospital care, hospitalization, and
post-hospitalization care. Both prevention and intervention
are key components for fracture care in the elderly patient.
At the completion of fellowship, it is expected that the fellow
has mastery of key concepts and principles in the basic sci-
ences and clinical disciplines in areas of geriatric trauma and
elder fracture care. In addition, the fellow is expected to mas-
ter surgical skills necessary for the management of complex
fractures in the elderly, periprosthetic fractures and
arthroplasty in the geriatric fracture population. Key compo-
nents of geriatric orthopaedic fellowship training are to obtain
the necessary knowledge base to create and manage a com-
prehensive geriatric fracture program with focused care con-
cepts in bone metabolism, perioperative care, rheumatology,
and palliative care and provide community medical education
related to best practices in geriatric orthopaedic care and frac-
ture prevention methods.
Interdisciplinary Team Exposure
Important considerations while treating older orthopaedic pa-
tients include iADLs and ADLs (independent activities of
daily living and activity of daily living), frailty, expected out-
comes versus optimal outcomes, pre-injury or baseline func-
tional status, quality of life, and social support. Several “geri-
atric giants” of impairment that appear in the elderly have
been established including immobility, instability, inconti-
nence, and impaired memory/intellect [5]. These often lead
to a loss of independence, higher risk for falls, and increased
frailty. Optimal care of the older orthopaedic patient depends
on a well-coordinated, collaborative team of experts along the
entire continuum of care.
Coordination and cooperation among a large interdisciplin-
ary team is critical to the care of older patients, particularly in
the setting of acute orthopaedic injury. Transition of care of an
older patient is critical to outcomes and may be a time of
particular vulnerability to older fracture patients [8].
Interdisciplinary care is an important part of care for older
patients, and fellowship training in geriatric orthopaedics ne-
cessitates a broad appreciation for the collaborative benefits of
many different disciplines (Fig. 1). Exposure to palliative care,
Curr Geri Rep (2017) 6:15–19
Fig. 1 Diagram of the continuum
of care in geriatric orthopaedic
patients
hospitalists, geriatricians, physical therapists, anesthesiolo-
gists, case managers, and emergency physician strategies for
care of elderly patients enhances an orthopaedic surgeons un-
derstanding of optimized care for older patients. In fellowship
training, the orthopaedic fellow should engage with many of
the other specialties and learn about CMS, Medicare require-
ments, and postacute care facilities.
Mobile Outreach
With over 70% of people over the age of 65 requiring long-
term assisted living or nursing home healthcare, this has sub-
stantial societal and financial consequences [9]. It is impera-
tive that we transform our current healthcare practices to ac-
commodate this dramatic shift in demographics and provide
the best healthcare possible to allow for the “baby boomer”
generation to preserve functional independence and a high
quality of life. Despite the societal concerns for the barriers
to healthcare for the older population, the question still re-
mains—how will we transform health care practices to over-
come the barriers to provide efficient, effective, safe, and sup-
portive healthcare for older patients while continuing to focus
on minimizing healthcare system costs?
There are many barriers to healthcare for older patients, not
only for patients but also for their family members and care-
givers out in the community. Travel to physician visits and
emergency departments for health care and follow-up visits
can be a significant disruption to patient’s environment, lead
to delirium, missed medication doses, and significant financial
costs for transportation or dependence on family members for
communication/cognitive needs. At the same time, helping
transport or attend clinic visits with older family members
17
helps facilitate patient care and communication but can lead
to significant loss of time at work and financial hardships for
family members. Often, transportation barriers or inability to
attend clinic visits due to transportation or physician availabil-
ity leads to unnecessary emergency department visits and even
readmissions to the hospital due to complex care needs. Under
current Medicare guidelines, a hospital stay of 3 days may be
required in order to get a patient into a skilled nursing facility
to provide supervised care, even if the patient was sent from a
skilled nursing facility for evaluation of a non-urgent issue.
Utilization of emerging technologies in telemedicine and cap-
italizing on the specialty expertise and training for advanced
practice providers could help overcome many barriers to or-
thopaedic care for older patients. Mobile outreach could pro-
vide a unique bridge to older patients in society by providing
efficient, effective specialty orthopaedic care and research
with the potential to transform the way we practice musculo-
skeletal care for older patients.
In order to build and maintain a successful outreach prac-
tice, strategic planning, business acumen, and specialty ad-
vanced practice provider training is necessary. Geriatric ortho-
paedic surgeons could be uniquely positioned to help organize
and lead mobile outreach and telemedicine clinics for muscu-
loskeletal care. Bringing care to the patient instead of the
patient coming to the provider may help alleviate many of
the barriers to caring for older patients both for acute trauma
such as fractures and for more chronic care such as osteoar-
thritis management. It also offers a tremendous opportunity
for education and easier communication among care providers
and family members. Fellowship-trained geriatric orthopaedic
surgeons may be pivotal to help bring this type of treatment
paradigm to the forefront of musculoskeletal care in elderly
patients.
18
Bone Health Clinic
Metabolic bone changes occur with aging, including decreased
bone mass and loss of biomechanical strength which leads to
osteopenia and osteoporosis. The loss of the bone’s ability to
resist fracture as individuals age places older individuals at high
risk for low-energy fractures that occur when a patient falls from
standing height or low heights (fragility fracture) [10].
Osteopenia and osteoporosis is often unnoticed and untreated
in people over the age of 65 until after fracture [11]. Over 1.5
million fragility fractures occur in the USA annually, with up to
50% of women and 30% of men over the age of 50 sustaining
fractures in the remainder of their lifetime [12, 13]. Prior fragility
fracture, fear of falling, and decline in mobility, coordination,
balance, and strength are some of the strongest predictors for
future fragility fracture. Estimated annual costs in the USA for
fragility fractures are over 17 billion dollars. The risk of second
fragility fracture is significantly higher than the risk for initial
fracture [14, 15]. Over 50% of patients with fragility hip fracture
may fall at least once in the year after hip fracture and nearly
30% may experience recurrent falls. These subsequent falls
place them at high risk for a second fracture [16–19].
Orthopaedic follow-up after a first fragility fracture may offer
a chance for meaningful education and intervention for osteo-
porosis and fall prevention.
As part of the “Own the Bone” program through the
American Orthopaedic Association, orthopaedic surgeons are
encouraged to help design and manage fracture liaison services.
This has led to a significant increase in interest and in education
of musculoskeletal health care providers to help manage osteo-
porosis. Screening labs such as calcium, vitamin D levels, and
DEXA screens can help establish fracture risk and provide data
to the patient to encourage bone health initiatives. Post injury
care visits offer an opportune time to discuss fall prevention
strategies, vitamin D and calcium supplementations, encourage
weight-bearing exercises, poly-pharmacy discussions, and pos-
sible initiation of osteoporosis medications.
Fractures may trigger inspiration and motivation for pre-
vention of future injury in the early setting of fracture care.
However, this can be a time commitment and additional edu-
cation that may not be feasible in a busy surgical practice. In
addition, many orthopaedic surgeons may not feel comfort-
able prescribing osteoporotic medications and although pri-
mary care providers and endocrinologists are often motivated
to help intervene for bone health, the timing of initiation of
screening and therapy may miss the a window of opportunity
where the patient may be most likely to feel motivated for
improved bone health due to transportation to clinic visits,
mobility challenges in the setting of acute fracture [6•].
Despite the availability and well-established literature demon-
strating the effectiveness of bisphosphonates, teripartide, and
other osteoporotic medications to prevent fragility fracture,
the prescribing and actual compliance of medication use in
Curr Geri Rep (2017) 6:15–19
fragility fracture patients is low [7•]. Geriatric orthopaedic
surgeons may be able to have meaningful impact in the early
fracture period by supervising and mentoring advanced prac-
tice providers to deliver bone health education in the early
fracture time period.
Surgical Experience
Operative treatment in older orthopaedic patients requires a
well-coordinated team of experts to optimize the patient for
early operative care and minimize unnecessary tests and con-
sultations that may increase costs and lead to delays in surgery
[7•]. The time to surgery, particularly in hip fractures, affects
the morbidity and mortality for the patient [20, 21].
Everything along the continuum of care from pre-hospital
transportation to medical clearance, perioperative care, post-
operative hospitalization, and post acute care is pivotal for the
outcome of the older patient. Details regarding this are beyond
the scope of this proposal; however, the geriatric orthopaedist
should have broad knowledge of these optimal treatment
guidelines.
Osteoporosis in older patients is also an important consid-
eration for surgical care. The microarchitecture and decreased
bone mass associated with osteoporosis decreases fracture
healing potential and makes implant fixation difficult. As the
structural integrity of the bone is compromised, the ability for
implants to “fix” into bone requires different techniques and
technology than fracture care for younger patients. Geriatric
orthopaedic surgeons need to have training about fixation
techniques for fragility fractures such as implant choice,
avoidance of multiple drill holes, and careful consideration
of stress risers in high-risk regions of bone that may lead to
hardware failure or subsequent periprosthetic fractures.
Implant techniques such as locked plating technology, dual
plating, far cortical locking screws, and bone augmentation
with cement, allograft bone, autograft bone, and bone substi-
tutes play an important role in treatment of osteoporotic bone
[22, 23•, 24]. Intraoperative changes in plan may be necessary
if initial fixation techniques do not provide the stability nec-
essary for the fracture to heal due to fracture comminution or
poor bone quality [25]. In addition, meticulous soft tissue
handling, wound closure, and prevention of wound break-
down are important for surgical care in older patients.
Dedicated fellowship surgical training techniques are impor-
tant to help with treatment and perhaps even advance current
implant and fixation technologies.
Conclusion
Elderly patients require a unique approach to orthopaedic care
that accounts for the complex musculoskeletal needs of the
Curr Geri Rep (2017) 6:15–19
patient. The bio-psychosocial needs often need to be consid-
ered in treatment strategies as well as for prevention strategies
to prevent future fragility fractures. Geriatric orthopaedic fel-
lowship training is a necessary paradigm shift to provide the
most efficient, effective, safe, supportive, and cost-effective
musculoskeletal healthcare possible for older patients.
Compliance with Ethical Standards
Conflict of Interest Julie Switzer reports grants from Stryker, outside
the submitted work. Carmen Quatman declares no conflict of interest.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
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